RIH Policy for Verification of the Patients Identity, Procedural Site, and Invasive Procedure Perfor

1
RIH Policy for Verification of the Patients
Identity, Procedural Site, and Invasive Procedure
Performed Outside the OR

• Keeping our patients safe at RIH
• Using the Universal Protocol

2
Medical Errors

• 44,000-98,000 Americans die each year as a result
  of preventable medical errors
• RIH has had three wrong sided procedures in a one
  year period
• Nationally 5-8 cases/month
• Wrong site 25-30
• Wrong procedure 10-14
• Wrong patient 12-17

3
Risk Factors for Errors

• Emergencies
• Lack of team work
• Multiple procedures
• Difficult time pressures
• Use of non-routine equipment
• Reliance on memory

4
How do we prevent errors?

• Study and improve processesbefore errors occur
  and afterwards with root cause analysis. Learn
  from good catches.
• Know and follow the hospital processes
  most have steps built in for safety.
• Work as a team. Each member has a voice.
• Use reminders and checklists.
• Make the Right Thing the Easy Thing

5
Admin-153

• RIH Policy for Verification of the Patients
  Identity, Procedural Site, and Invasive Procedure
  Performed Outside the OR
• Supports the Universal Protocols three steps
• Pre-procedure verification
• Marking the site/SIGN THE LINE
• Time out immediately before the procedure

6
Invasive Procedures

• Puncture or incision of the skin
• Insertion of an instrument into the body
• Percutaneous aspirations
• Biopsies
• Cardiac and Vascular catheterizations
• Any procedure requiring sedation
• NOT minor procedures such as Venipuncture,
  Peripheral IV, NG tube, and Foley catheter
• See new Policy Addendum to help clarify

7
Policy Statement

• Informed consent is required
• Obtained by procedural physician or LIP
• Includes patients full name, date of birth, and a
  full description of the procedure including site
  and side if applicable
• Is signed, dated, and timed

8
Policy Statement

• Patient Identifiers
• Name and DOB
• Prior to any diagnostic or therapeutic procedure,
  the nurse, technologist, medical assistant,
  procedural physician, or LIP will
• Visually check the patients ID band/approved
  identifier
• Verbally confirm patients ID with patient and/or
  representative whenever possible

9
Policy Statement

• Documents
• The nurse, technologist, or medical assistant
  will check chart for
• Consent
• H P or progress note
• These documents will be used to confirm
  correct procedure and site/side.

10
Policy Statement

• Site marking when laterality is involved or when
  there is duplication or multiple levels
• Two stage process with indelible marker
• Nurse, technologist, or medical assistant will
  mark incision site as close as possible with a
  straight line. Involve patient when possible.
• Proceduralist will verify site and place initials
  on line.
• SIGN THE LINE (No more Xs)
• Mark must be visible after patient is draped.

11
TIME OUT

• Immediately prior to procedure
• All team members present will actively confirm
• Correct patient
• Correct procedure
• Correct site and side where predetermined

12
Starting on May 6th

• The New RIH Invasive Procedure Verification
  Checklist form
• Use to document the 3 steps of the Universal
  Protocol.
• Do the steps, but no checkoffs just sign the
  boxes.
• The Verification Checklist box will be removed
  from the Procedure Note and Sedation Monitoring
  Record forms.

13
Invasive Procedure Verification Checklist

• Part A completion on form
• Only at patient arrival to a pre-procedure area
• Verify name and DOB with patient chart/plate and
  verbally with patient or representative if
  possible
• Check that consent is present
• Check that diagnosis or indication for procedure
  is present in the record
• Sign the box to the right of Part A

14
Invasive Procedure Verification Checklist

• Part B completion on form
• In procedure area or at the bedside
• Present team members together in a call out
  process will verify
• Name and DOB with patient chart/plate and
  verbally with patient or representative if
  possible
• Consent is present and completed
• Diagnosis or indication for procedure is in the
  record
• Relevant test results/images are properly
  labeled, displayed, consulted
• All necessary equipment is present
• Then appropriately sign in the boxes on right of
  form.

15
Invasive Procedure Verification Checklist

• Part B completion on form
• In procedure area or at the bedside
• Mark site as required. Sign the line.
• Involve patient when possible
• Necessary for laterality, duplication, or
  multiple levels. (Exceptions listed in policy,
  Admin-153)
• Two stages straight line near incision site and
  initials of proceduralist when verified with
  reference to plan, consent, HP /or X-ray
• Indelible mark visible after draping

16
Invasive Procedure Verification Checklist

• Part B completion on form
• In procedure area or at the bedside
• All members actively confirm in time out
• Correct patient
• Correct procedure
• Correct site
• RN/Tech/MA initials to affirm time out was
  completed immediately prior to procedure start.

17
Invasive Procedure Verification Checklist

• Variation or exceptions in verification procedure
• Patient refuses site marking
• Check applicable box
• Emergent situation
• Check applicable box write rationale
• Fax a copy of checklist to Quality Management

18
Third signature requirement?

• Must a manager sign the form as a witness to the
  verification process?
• No mention in the policy or on the form
• Left to managers discretion
• Recommended for low volume or noncompliant
  areas/units
• Blank space for initials/signature on lower right
  corner of the form